Part 6: Detection and Prevention of Foot Problems in Type 2 Diabetes

pulse was bilaterally absent in 1.8% and unilaterally absent in 3.0% (Robertson et al,1990).McGee and Boyko (1998) reviewed papers published between 1966 and 1997regarding bedside diagnosis of PVD. The majority of the 17 studies identified was onpeople without diabetes. The authors concluded that the following positive findingswere helpful in diagnosing PVD: abnormal pedal pulses, a unilateral cold extremity,prolonged venous filling time and a femoral bruit. In deciding whether a pulse ispresent or absent, clinicians demonstrated fair to almost perfect agreement (McGee &Boyko, 1998).In a cross-sectional study of 631 veterans with diabetes attending a general medicalclinic in the US, history and clinical examination were evaluated in detecting PVD(Boyko et al, 1997). The criterion used for PVD was an ABI ≤0.5, derived fromDoppler blood pressure measurements of ankle and brachial systolic pressures. Pulseswere recorded as absent in one foot only if both pulses were absent. Absent peripheralfoot pulses had a sensitivity of 65% and a specificity of 78% for detecting an ABIwith ≤0.5. Diminished foot pulses and delayed venous filling were associated with thehighest positive likelihood ratios. Classical signs such as decreased hair, or skinatrophy were not clinically useful. Diminished or absent peripheral pulses in a leg hada sensitivity of 65.2% and a specificity of 78.3% with a positive likelihood ratio of 3(CI 2.3-3.9) and a negative likelihood ratio of 0.4 (CI 0.3-0.7) for an ABI < 0.5. Inmultivariate analysis a negative history of PVD and palpable peripheral pulseseffectively ruled out the presence of PVD (Boyko et al, 1997).A prospective study in Denmark examined the relationship between pedal pulses andmeasurement of distal systolic pressure in a group of 132 people without diabetessuspected of having PVD (data on 15 people with only one leg were not included)(Christensen et al, 1989). The group was aged 62 years, half were men and all hadclaudication, rest pain or ulcers of presumed arteriosclerotic origin. The presence ofpalpable pedal pulses was usually associated with an ankle index >50% (anklesystolic pressure as a percentage of systemic systolic pressure) and a toe systolicpressure >40 mmHg.. The median ankle index was 94% in the 52 people withpalpable pulses in both feet, 50% in the 38 people without palpable pulses in bothfeet, and 54% in the 27 people with palpable pulses in only one foot. Repeatedassessment of the pulses in the feet over time was found to be useful in following theprogress of peripheral arterial disease as well as healing of any ulcer present.The absence of foot pulses increases the likelihood of amputationThe absence of peripheral pulses has prognostic significance. In a study of 314 peoplewith mainly Type 2 diabetes and foot ulceration who were followed prospectively, theabsence of pedal pulses was more common in people who underwent amputation thanin those who had an ulcer which healed (77 v 44%, p